Using a CO 2 laser is good for removing cysts as well as locating and removing scar tissue, inflamed and clogged hair follicles, and excess tissue. In general practice the term interdigital cyst is commonly used to describe a range of conditions affecting the feet. Without more context, it is hard to determine their exact intentions. However, a cyst is defined as a well-circumscribed epithelium-lined cavity filled […]1. Factors Leading to Interdigital Cysts in Dogs. They are prone. Here are the causes of interdigital cysts and appropriate treatments for them. Instead, it can help keep the area clean and relieve the itchiness commonly associated with the infection. Chronic pododermatitis with interdigital furunculosis is a common and frustrating problem in dogs. Tim Nuttall. These blisters can be caused by a variety of factors, including: Friction and Irritation: Dogs who spend excessive time on hard surfaces or engage in intense physical activities may experience friction between their toes, leading to blisters. They are not one single issue and have various causes. 95 month Fiesty Dog Marketplace Vendor. Lera talks about interdigital cysts with Winston, a two-year-old male English Bulldog. First soak the area on the paw in warm water and Epsom salt. The masses are painful and may cause lameness. An interdigital cyst is a fluid-filled sac that forms between the pads of your dog’s feet. toes). Dogs may limp from the pain, especially when. 2023. Tracy DVM. My 12 year old Siberian husky has an interdigital cyst. Interdigital cysts are very common in dogs with allergies and they can be very painful. 18 Feb 2022. It will be swollen and infected with bacteria. My dog has a raised lump on the top of his paw with some pus. Facebook. Remember that to be a cyst there must be a hollow cavity within the mass that holds a liquid or dried liquid substance. It’s a very painful oral cancer for dogs. Dogs’ Interdigital Cyst Cleanse and Detoxification Treatment. These painful cysts can rupture and leak clear or blood-tinged fluid. It can be single or multifocal, and it is often associated with foreign body reactions to embedded hair shafts. Interdigital Cysts Defined: Interdigital cysts are small, raised lumps or pustules that typically emerge between the toes of dogs, nestled within the interdigital webbing. Dr. For instance, you’d find an interdigital cyst on the paw and a meibomian gland cyst on the eye. You don’t want infections to set in while trying to drain this thing so take time with this step. Interdigital ‘cysts’ are a common, recurrent and painful problem in many dogs. (Actually interdigital cyst is a common way to refer to this kind of bump, though technically incorrect. Hemorrhoid cream. The most common symptoms of interdigital cysts in dogs include: Limping: Dogs with interdigital cysts often exhibit lameness or favor the affected paw. The most common reason for IF is allergy (Image 1 and Figure 1). Made in the ancient traditions of poultices, by hand, and without metal implements. Works but as soon as we slow down dose, it comes back again. /Jan. Interdigital ‘cysts’ are a common, recurrent and painful problem in many dogs. Interdigital cysts are a series of inflamed and often infected tissue between your dog’s toes. 1. Natural interdigital cysts treatment comes from a variety of sources. Pododermatitis or interdigital cysts, which are filled with fluid, are related to the bristly hair between the toe pads and are believed to be caused by the hair keratin being forcefully pushed into the skin by the movement of the dog, by walking on graveled and rough terrain or by injury to the webbing between the toes. Find out how to manage interdigital cysts in dogs using natural remedies at home. Unless the underlying infection can be controlled, there is a strong likelihood of return of the cyst or development of a similar cyst in another location on the feet. Premium Explore Gaming. It is a multifactorial condition with primary, predisposing and perpetuating causes that lead to the secondary infections. 11. They are most commonly found on the front paws. There are three major treatment options of interdigital cysts in dogs: medical therapy, surgery, and CO2 laser: Medical therapy: Medications include oral or topical anti-inflammatories, like steroids,. . Interdigital furuncles are often incorrectly referred to as interdigital cysts. To help you recognize interdigital cysts, integrative veterinarian Dr. Interdigital furuncles respond best to a combination of topical and systemic therapy. Ask for help, 24/7. In these dogs, diagnosing and managing the underlying cause of itching, such as allergies, is part of treating and preventing interdigital cysts. Cephalexin (20 mg/kg, PO, tid, or 30 mg/kg, PO, bid) is recommended for 4-6 wk of initial therapy. Natural Dog Company provides health & wellness solutions for dogs and peace of mind for dog parents. Bathing his feet once a day, with a mild baby shampoo, (rinse off any soap completely), followed by a foot soak with a small amount of apple cider vinegar will. Certain types of cysts are common in specific areas. Receive up to 40% Product Discount! Register Now!EnteDerm Ointment Indications. (actigall) 10 mg/kg PO daily, Vitamin E 400 IU PO every 12 hourse. . Dogs that lick or chew at their paws can cause hair and skin irritation that leads to interdigital cysts. “They’re filled with what’s called sebum or wet wax,” he says. Step 3 : Clean Your Dog’s Cyst. In these dogs, diagnosing and managing the underlying cause of itching, such as allergies, is part of treating and preventing interdigital cysts. Swelling:. What Is An Interdigital Cyst? Interdigital cysts, also known as an interdigital furuncle, are painful lesions or growths that form on the webbing between a dog's toes. How to pick the right paw balm. Swelling or a lump in the webbing between your dog’s toes. Our vet said 100% they are not interdigital cysts but he said he didn't know for sure exactly. This is because the lesions grow in size and eventually rupture. You can wipe under the paw and between the digits with the. Natural interdigital cysts treatment comes from a variety of sources. These can range from mites to ingrown hairs to allergies. Tuffers feet were often irritated and itchy. They are most commonly found on the front paws. One of the most common foot problems is interdigital pyoderma -- infections between the toes. 1M views. Dr. 2,858 Satisfied Customers. It will also draw out a foreign body that might be causing the problem. Earth Clinic has several success stories of owners giving their dogs turmeric, an Indian spice known for helping fight infection, some forms of cancer and inflammation. This cyst on your dog’s paw is most likely what’s commonly called an interdigital cyst. They can also be called interdigital furuncles, follicular pododermatitis, or podofurunculosis. It is characterised by the presence of recurrent interdigital furunculosis. And the best source of magnesium is Epsom salts. Prescribing antibiotic therapy, a steroid or a mite killer is usually the first line of defense. We have seen the vet with her and they say there is very little they can do. These are also called interdigital folliculitis or furunculosis. today it had a bit of transparent liquid + blood coming out of it. Is it safe to allow Pepper to play? Additionally, can she play in a river? JA: I'll do all I can to help. Home treatment should not be attempted by novices, it is however a step available to those experienced in dogs and the possible repercussions of interdigital cysts. You can soak the foot in warm water with Epsom’s salts for around 10 mins several times a day, followed by another soak in diluted. See more videos about Cyst on Dog, Dog Cyst Ear Removal, Dog Cyst, Dog Cyst Surgery, Dog Cyst Removal, Draining Dog Cyst. Secondary infections can occur as a result of these lesions. Dogs can have one cyst or multiple cysts, depending on what caused them and how long it has been going on. because puncture can lead to infection. They are small to medium and can become irritated and inflamed because dogs frequently lick them. Klein explains that sebaceous cysts, one of the easiest types to become infected, are prevalent in dogs. Most dogs tend to have hair of some length between their toes. How to get rid of interdigital cysts on a dog’s paw without professional treatment: – Soak the affected paw in warm, saltwater for 5-10 minutes several times daily. If there is licking, you must fit the dog with an elizabethan collar, which you can buy from your vet or from most pet stores. 1. 1. Affected tissues may include interdigital spaces, footpads, nail folds (paronychia), and nails. Introduction. 6. Photo courtesy of Dr. There are several factors that contribute to their appearance, so it’s important to be acquainted with them. Gomez SM, Morris DO, Rosenbaum MR, Goldschmidt MH. LisaS716. “Interdigital cyst” is a misnomer; cysts are thin-walled sac that contains fluid. When bacteria enter a hair follicle, the follicle becomes inflamed and swollen. Environment Skin trauma from cages or rough ground can damage hair follicles. They told me if it didn’t go away with rest and bothered my dog while walking around then surgery might be the last option. They are most commonly found on the front paws. Environment Skin trauma from cages or rough ground can damage hair follicles. Other pre-disposed factors include obesity which is the addition of unusual weight. Interdigital cysts are large bumps, or nodules, between a dog's toes. After the first few minutes, massage the cyst. Specialities include: Dog Veterinary, Dog Medicine, Dog Diseases, Small Animal Veterinary. 4 year old male Labrador Retriever neutered healthy I just. Facebook. These types of cysts on dogs are typically firm and not easily moveable. In this article, we will take a look at all matters related to interdigital cysts in dogs, including common causes of cysts in dogs' paws, what happens if cysts are left untreated, and how to prevent interdigital cysts in dogs. Soak your dog’s paws in an Epsom salts bath to open the skin. Affected dogs may limp and have draining sores between their toes. Normally these. Anti-inflammatories. Sulfodene Dog Wound Care Ointment, Relieves Pain & Prevents Infection For Dog Cuts, Scrapes, Bites and Injuries, 2 Ounce. In these dogs, diagnosing and managing the underlying cause of itching, such as allergies, is part of treating and preventing interdigital cysts. Different Types of Interdigital. In summary, interdigital cysts are incredibly hard to prevent, but proper treatment and a daily physical examination of your bulldog will keep the cysts in check. Interdigital cysts can be caused by a variety of factors such as allergies, infections, tumors, and even foreign objects that have become lodged in the paw. I’m not clear on the amount of Olive Leaf Extract. 18. BULLDOG INTERDIGITAL THERAPEUTICS BULLDOG INTERDIGITAL CYST / THERAPEUTIC TOPICAL ANTISEPTIC . The most common cause is an underlying skin infection. 2. Often mistaken for ‘just a blister,’ these cysts can be a source of great discomfort for your pet. Interdigital cysts are often seen in dog breeds predisposed to atopy, such as West Highland White Terriers 2. While a majority of dog owners will consider limping as a sign of an injury, it is one of the primary symptoms of interdigital cysts in dogs. I noticed today and he. 6. We know it is a furuncle because that is how it looks under a microscope. 📌 Want to learn how to make your own raw o. If you're not comfortable with what the vet suggested, it may be ideal to go to another to get a second opinion. There are numerous home remedies to treat interdigital cysts. Swelling: The cysts can cause swelling in the affected area, making it painful to touch. Home Treatment For Interdigital Cysts. Year 2 started April 8, 2013 on her rear left hock/upper thigh and spread down that leg and all the way up to beneath her tail. Following is a list of more specific events and occurrences that can lead to infection: Embedded foreign objects, such as splinters or foxtails; Direct contact with chemicals or other toxins; Ringworm; Interdigital pyoderma; Interdigital cysts; Cancer. There may be nodules (bumps) or fungal lesions. Dogs that lick or chew at their paws can cause hair and skin irritation that leads to interdigital cysts. However, because the lesions are pyogranulomatous, it may be difficult for antibiotics to penetrate them; therefore, >8 wk of systemic antibiotic therapy may be. Interdigital pyoderma in dogs is a common condition seen in veterinary practice and can be a frustrating and challenging condition to treat at times. Lesions include interdigital erythema, edema, nodules, hemorrhagic bullae, hemorrhagic draining tracts, ulcers, and scarring. Often what is done is the wound is kept open and managed as an open wound, however it really depends on the specific situation. Licking the pru-ritic area causes hair shafts to break, leavingWhile sometimes these toxins build up and result in interdigital cysts, dogs might also show other symptoms instead, such as red eyes and ear discharge or skin irritations and itchiness. In order to better understand their etiology, we completed a retrospective analysis of epidemiologic factors by using the clinical records from 743 research Beagles at our research site. 2020. Interdigital cysts in dogs can be painful for your pup and somewhat challenging to treat. Once inflamed, these lesions are furuncles, commonly found on the front feet’s top but may affect all four feet. Skin scrapings, blood tests and biopsies can all provide clues as. Vet Dermatol. An ‘interdigital cyst’ is a lump which appears between the digits (commonly referred to as ‘toes’) of the dog's paw. Your vet may try a variety of options including diet changes, antibiotic therapy, anti-inflammatories, antifungal shampoos and more. The feet and paws are often red (inflamed) and swollen. A case of disseminated cysts in a dog is described. Interdigital furunculosis is a deep bacterial infection that causes painful nodules in the interdigital webs of dogs. DVM. Golden retrievers develop. One or more nodules may be present and they are usually found in the dog’s front paws. Disease Spotlight: Interdigital Cysts | Animal Dermatology Referral Clinic (ADRC) This is one of the most frustrating conditions seen in the veterinary dermatology practice. Interdigital ‘cyst’ are a common, recurrent problem in many dogs. 5. Interdigital cysts usually appear as red nodules filled with blood and/or pus. This cyst on your dog’s paw is most likely what’s commonly called an interdigital cyst. They just keep coming back, he constantly licks at his paws, idk what else to do. Here’s what to look for. In these dogs, diagnosing and managing the underlying cause of itching, such as allergies, is part of treating and preventing interdigital cysts. Expert will respond in minutes. Owner / veterinarian. Retired. Side Note: If this is a regular occurrence, you. Recurrence is very likely unless the primary cause is detected & treated. 6. They can also be called interdigital furuncles, follicular pododermatitis, or podofurunculosis. Side Note: If this is a regular occurrence, you. It can be a foreign body stuck in the paw pad such as glass or a weed seed, an ingrown hair follicle, an interdigital cyst, corns (more common in greyhounds), warts etc. Give the one you pick a week trial and if it isn't working try another. Candelilla wax. Some use the term to describe any swelling and inflammation in the interdigital webs, others use it for inflammation of any part of the foot. The painful lumps found between a dog’s toes are more accurately called a furuncle – also known as a boil – and is caused by an infected hair follicle. Heat around the lump. Viral papillomas are classically fimbriated, meaning they are round but often have a rough, almost jagged surface reminiscent of a sea anemone or a cauliflower. These types of cysts on dogs are typically firm and not easily moveable. These cysts will occur between the toes and around the bottoms of the feet. Tuffer’s treatment consisted of antibiotics and topical treatment. Ask for help, 24/7. 7. antiseptic swabs, to prevent the area from becoming infected and to stop infections spreading. diagnosis and management of these conditions can massively reduce the impact of the cysts. Cysts are typical on the paw for a Bulldog now and again. Effective management involves: Identifying and managing the underlying cause of the trauma. While a majority of dog owners will consider limping as a sign of an injury, it is one of the primary symptoms of interdigital cysts in dogs. 1. They are most commonly seen in the webbing between the dog toes. An interdigital cyst is a fluid-filled sac that forms between the pads of your dog’s feet. The condition isMy dog has interdigital cysts that are getting so bad that. 3475 posts · Joined 2006. Interdigital cysts usually appear as red nodules filled with blood and/or pus. I started seeing swelling on one foot and specifically one toe. . Ear (otitis) The drug is. The most common cause is an. Health & Safety. The moist webbing between the toes promotes microbial overgrowth. Denise Nelson. Repeat the process 10 times, three times a day, for one week. Sebaceous Cysts. Below is a list of the best home treatments you can start doing today in order to minimize the pain for your dog: Soaking the dog’s paw in Epsom salts twice a day. 7. Home Treatment For Interdigital Cysts. Pathogenesis of canine interdigital palmar and plantar comedones and follicular cysts, and their response to laser surgery. In general practice the term interdigital cyst is commonly used to describe a range of conditions affecting the feet. Swelling: The cysts can cause swelling in the affected area, making it painful to touch. Interdigital cysts can make your dog’s paws painful and irritated. Digestive problems are a common consequence after antibiotic use. Boots can be used to protect the foot outdoors until fully healed. June 4, 2018 Dog’s Painful Growths between Toes Removed by Laser Interdigital cysts are fairly common Poor Ares was in pain. Interdigital follicular cysts are a common reason for a dog to be presented with lesions confined only to the feet. DVM. petdrz. Recurrence is very likely unless the primary cause is detected & treated. After the cyst is drained, most vets will opt to remove it entirely (especially if it has become infected). Dr. The cysts develop in the form of hard, raised lumps. These cysts typically form in the webbing between a dog's toes, and they can be quite. are a relatively common skin condition that affects dogs. If the dog has interdigital hemorrhagic bulla and draining lesions that occur randomly in various interdigital spaces, then the presence of follicular cysts is not very likely (Figure. They enlarge in size and appear as a nodule or “cyst” between the toes. It may form when pressure is put on your dog’s foot and causes fluid to build up in the skin between the toes. Take some hydrogen peroxide and sterilize the area where the cyst is located. Symptoms resolved after this course of treatment. Interdigital furuncles, often incorrectly referred to as interdigital cysts, are painful nodular lesions located in the interdigital webs of dogs. Histologically, these lesions represent areas of nodular pyogranulomatous inflammation—they are almost never cystic. Here is a list of treatments that is commonly recommended: Residual topical rinses and shampoos. 6 per cent) of a total of 5923 dogs were presented for examination with interdigital cysts. This is when a surgeon removes the proliferative and redundant skin tissue between the toes. Causes of Interdigital Cysts on Dogs. The result is inflammation and the formation of a cyst or cysts. A furuncle is simply another name for a boil – it is an infection of the hair follicle in the skin between your Bulldog’s toes. 3475 posts · Joined 2006. Interdigital cysts are also common in dogs with allergies and can be uncomfortable for dogs. And the best source of magnesium is Epsom salts. Interdigital cysts are also common in dogs with allergies and can be uncomfortable for dogs. The more gentle you are with this process, the better- trust me on one. Reducing exposure to further traumas. They are most commonly found on the front paws. An interdigital cyst is a benign, fluid-filled sac that is most commonly found on the webbing between the toes of dogs. They could have simply been sharing an observation, or they may have been implying that you are not as knowledgeable as you think. Customer: My dog, Pepper, was diagnosed with interdigital cyst on one of her paws. Pain and Discomfort: Dogs may lick, chew,Pododermatitis (Interdigital Dermatitis) is the inflammation of the interdigital skin; the area of skin in between the toes and footpads. The most common symptoms of interdigital cysts in dogs include: Limping: Dogs with interdigital cysts often exhibit lameness or favor the affected paw. These sores, also known as interdigital furunculosis, often involve a bacterial infection. Make your your dog or cat has plenty of clean water. Although this. Those can result from any injury or inflammation of the skin in the area. Interdigital cysts are large bumps, or nodules, between a dog’s toes. Started in September and cleared up in Dec. Put the dog on a diet to lower his. The prognosis for dogs with cysts is excellent, but the treatment will depend on both the type and location of the cyst. Sebaceous Cysts Average Cost. 3, 4), and the. Interdigital cyst. Rosenberg is one of very few dermatologists in the world who perform this surgery. Details. Roy Kraemer is the owner and creator of Vet4Bulldog. 2. 2008;19(3):134–141. Remember that to be a cyst there must be a hollow cavity within the mass that holds a liquid or dried liquid substance. They also can open and ooze blood or. Dogs that lick or chew at their paws can cause hair and skin irritation that leads to interdigital cysts. For instance, a cyst on a tail can’t be so easily removed due to the lack of available skin to. 7. 1 dog developed a low-grade oral spindle cell sarcoma after 320 days. As the name might imply, it tends to affect the interdigital region, which is the area between the toes. However, cysts found between a dog's toes. Do interdigital cysts go away? All of that said, your veterinarian does understand that interdigital cysts (furuncles) aren’t so “simple. Interdigital Cysts. The most common symptoms of interdigital cysts in dogs include: Limping: Dogs with interdigital cysts often exhibit lameness or favor the affected paw. The SCC does not retain its appearance as a solid mass. Keeping his feet meticulously dry and clean is necessary. Interdigital cysts are masses or lumps that can form on the feet of dogs. Unlike tumors, these cysts are usually red and filled with pus or blood. A sebaceous cyst is a common occurrence in dogs. While they can occur in any breed of dog, cysts are most commonly seen in large and giant breeds. That rupture leaves the skin open and at risk of bacterial infection. It can be blistery and infected, painful, and difficult to walk on. Looks like a small hole in between toes raised bump with pin. We. 1. Sebaceous cysts develop from sebaceous glands — aka oil-producing glands that are often attached to hair follicles. Dr. In these dogs, diagnosing and managing the underlying cause of itching, such as allergies, is part of treating and preventing interdigital cysts. Rub preparation H on the cysts. These are considered rare. Another paw bump of concern is interdigital cysts in dogs. 1,2 Although pododermatitis in many of these conditions represents a clinical manifestation of a more extensive disease, some dogs have lesions confined strictly to their paws. In these dogs, diagnosing and managing the underlying cause of itching, such as allergies, is part of treating and preventing interdigital cysts. Expert will respond in minutes. Biopsy is necessary to diagnose interdigital cysts or comedones. Sadie - 3 By chatting and providing personal. Soak your dog’s paws in an Epsom salts bath to open the skin. Cysts (pockets of fluid or other material under the skin) or comedones (clogged hair follicles) also occur on the webbing between toes. Interdigital Cyst. Treating the secondary infections will often result in only a short to medium term resolution. . Causes of interdigital cysts in dogs. Chronic pododermatitis with interdigital furunculosis is a common and frustrating problem in dogs. #7 · Feb 24, 2020. A dog interdigital cyst is a sac-like growth that develops between the toes of a dog paw. Factors examined included age, gen. In: Veterinary Dermatology 19 (3): 134-141. com and the founder of a bulldog and French bulldog practice located in souther. Sometimes the toe may need to be removed as well, but that is rare. Interdigital cysts, also known as interdigital furuncles or pododermatitis, are a relatively common skin condition that affects dogs. Pain and Discomfort: Dogs may lick, chew,The cyst can then either be allowed to drain by itself into a pan, or suction can be applied to remove the contents. An abscess, or localized infection of the skin, between the toes is also called an interdigital furuncle. Interdigital follicular cysts are a common reason for a dog to be presented with lesions confined only to the feet. The most common symptoms of interdigital cysts in dogs include: Limping: Dogs with interdigital cysts often exhibit lameness or favor the affected paw. Allergies. The paw (s) may be inflamed only, or inflamed and infected with any combination of microbes. When bacteria enter a hair follicle, the follicle becomes inflamed and swollen. are a relatively common skin condition that affects dogs. Interdigital cysts. Interdigital cysts, as the name would imply, appear between the digits (i. Dr. These blisters can be caused by a variety of factors, including: Friction and Irritation: Dogs who spend excessive time on hard surfaces or engage in intense physical activities may experience friction between their toes, leading to blisters. If the cysts are caused by a foreign object, then that object must be removed first. Abstract. For most dogs, the best treatment for a ruptured cruciate ligament (ACL/CCL) is surgery. Dogs that lick or chew at their paws can cause hair and skin irritation that leads to interdigital cysts. I am wanting to treat a dog with what I believe to be an. What Are Interdigital Cysts in Dogs? An interdigital cyst is an abscess that forms between the toes of a dog’s front paws. Discoloration. Only two dogs continued to develop interdigital cysts. The nodules form and then rupture, and that results in even more irritation to the area. Interdigital cysts in dogs can be painful for your pup and somewhat challenging to treat. The lesions begin ventrally as a follicular cyst, and progress to form a. Dogs with a history of neoplastic disease and pregnant bitches were excluded as recommended by the manufacturer of the laser device. Vitamin E. Veterinarian. Do not give OP specific treatment. Similar to tumors, other symptoms of cysts may include irritated. Dogs that lick or chew at their paws can cause hair and skin irritation that leads to interdigital cysts. Some breeds, including the English Bulldog, are more prone to the development. Dogs that lick or chew at their paws can cause hair and skin irritation that leads to interdigital cysts. Zyan, MBISS GCHG Vondura's Let's Go Crazy TKN ORT. If the cyst is large, you may need to have it drained by a veterinarian. January 24, 2022. Infections: Bacterial, fungal, or yeast infections can cause cysts to form between your. 99 month Fiesty Dog Pals Membership, 7 Day Free Trial/$29. It’s mostly due to injuries of the hair shaft and follicles due to traumatic implantation. A complete dermatological examination was then performed, the interdigital lesions and their location were recorded, and multiple cytological samples from each lesion examined to rule out. We see this condition as a structural/functional problem with dogs who have a limb deformity; for example, bulldogs with bow legs. While not specific to beagles, they can occur in any breed. Interdigital ‘cyst’ are a common, recurrent problem in many dogs. . In these dogs, diagnosing and managing the underlying cause of itching, such as allergies, is part of treating and preventing interdigital cysts. Blood blisters form on the lumps, which eventually break down. Members enjoy round-the-clock access to 12,000+ verified Experts, including doctors, lawyers, tech support, mechanics, vets, home repair pros, more. One was dermal, the other an anal sac. The presence of cysts, micro abscesses and scar tissue can inhibit the penetration of water-soluble antibiotics, and this should be considered when selecting drugs and doses. This is an infection and inflammation of the haired skin between the toes that causes a swollen cyst to develop. Many need oral antibiotics and or anti-inflammatory medications to get them to completely heal. .